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Simulation-based assessment of care for an infant with cardiogenic shock in the emergency department
Hani Alsaedi1, Zachary J Berrens1, Riad Lutfi1
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA.
Insights
General emergency departments (GEDs) need better preparation for resuscitating neonates with congenital heart disease (CHD). Simulation revealed significant gaps in care, particularly in critical interventions for neonates with CHD in cardiogenic shock.
Area of Science:
- Pediatric Emergency Medicine
- Neonatal Resuscitation
- Congenital Heart Disease (CHD) Management
Background:
- Congenital heart disease (CHD) is a leading cause of infant mortality due to birth defects.
- Neonates with undiagnosed CHD often require resuscitation in general emergency departments (GEDs), which may be less equipped than specialized pediatric centers.
- This disparity can lead to suboptimal care for critically ill neonates.
Purpose of the Study:
- To assess the quality of resuscitative care for neonates with CHD in cardiogenic shock within a simulated GED setting.
- To identify the impact of team composition and GED-specific variables on the effectiveness of care processes.
Main Methods:
- A prospective, simulation-based study involving interdisciplinary teams in participating GEDs.
- Utilized a simulated neonate with coarctation of the aorta in cardiogenic shock.
- Measured adherence to best practices using a 15-item composite adherence score (CAS), stratified into CHD-critical and general resuscitation items.
Main Results:
- The study included 32 teams from 12 GEDs, comprising nurses, physicians, and respiratory therapists.
- The overall median CAS was 84, but the median CAS for CHD-critical items was significantly lower at 34.5.
- Key underperformed tasks included checking pulses (44%), obtaining blood pressure (25%), and administering prostaglandin E1 (22%).
Conclusions:
- In situ simulation identified critical gaps in the resuscitation of neonates with CHD in cardiogenic shock within GEDs.
- These findings underscore the need for targeted improvement programs to enhance care for high-stakes pediatric emergencies in general emergency settings.
Background:
Congenital heart disease (CHD) is the leading cause of infant deaths associated with birth defects. Neonates with undiagnosed CHD often present to general emergency departments (GEDs) for initial resuscitation that are less prepared than paediatric centres, resulting in disparities in the quality of care. Neonates with undiagnosed CHD represent a challenge; thus, it is necessary for GEDs to be prepared for this population.
Aim:
To evaluate the process of resuscitative care provided to a neonate in cardiogenic shock due to CHD in the GEDs in a simulated setting and to describe the impact of teams and GED variables on the process of care.
Methods:
This is a prospective simulation-based assessment of the process of care provided to a neonate with coarctation of the aorta in cardiogenic shock. Simulation sessions were conducted at participating GEDs utilizing each GED's interdisciplinary team and resources. The primary outcome was adherence to best practice, as measured by a 15-item overall composite adherence score (CAS). In addition, we stratified the overall CAS into CHD-critical items and the general resuscitation items CAS. The secondary outcome was the impact of the team's and GED's characteristics on the scores.
Results:
This study enrolled 32 teams from 12 GEDs. Among 161 participants, 103 (63.97%) were registered nurses, 33 (20.50%) were physicians, 17 (10.56%) were respiratory therapists, and 8 (4.97%) were other medical professionals. The overall median CAS was 84, with the CHD-critical items having a median CAS of 34.5. The most underperformed tasks are checking pulses on the upper and lower extremities (44%), obtaining blood pressure in the upper and lower extremities (25%), and administering prostaglandin E1 (22%).
Conclusions:
Using in situ simulation in a set of GEDs, we revealed gaps in the resuscitation care of neonates with CHD in cardiogenic shock.
Relevance To Clinical Practice:
These findings highlight the importance of targeted improvement programs for high-stakes illnesses in GED.
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